CommentaryHarm reduction for young people who use prescription opioids extra-medically: Obstacles and opportunities
Introduction
Concomitant with a dramatic rise in the prescribing and sale of opioid pain relievers, extra-medical prescription opioid (EMPO) use – defined as intentional opioid use without a prescription or use of one's own prescription outside of prescribed parameters – is one of the fastest growing forms of drug use in the United States (National Institutes on Drug Abuse, 2011). The prevalence of EMPO use is highest among young people aged 18–25, with an estimated 6 million (1 in 5) young adults reporting lifetime use and 2.7 million (1 in 12) reporting use in the past year (Center for Behavioral Health Statistics and Quality, 2015). High rates of EMPO use among young people have also been observed internationally (Brands et al., 2010, Ghandour et al., 2012).
Increasing EMPO use has resulted in severe public health, social, and economic problems (Kolodny et al., 2015). The rate of EMPO-attributable fatal overdose has continued to climb over the past decade, and by 2011 was four times that observed in 1999 (Chen, Hedegaard, & Warner, 2014). Substantial increases in the number of emergency visits related to EMPO use have been observed, from 172,738 in 2004 to 488,004 in 2011 (Substance Abuse and Mental Health Services Administration, 2013). Between 2002 and 2012, there was a 370% increase in the rate of individuals seeking publicly funded treatment for addiction to prescription opioids (Substance Abuse and Mental Health Services Administration, 2014).
Evidence also suggests that growth in the sale, use, and non-medical use of prescription opioids have contributed to a dramatic rise in heroin use in the United States. Analyses of data from the National Survey of Drug Use and Health (NSDUH) suggests that the risk of heroin initiation is approximately 20 times higher among persons who report extra-medical use of prescription opioids, with four out of five recent heroin initiates reporting prior EMPO use (Muhuri, Gfroerer, & Davies, 2013). Young adult populations are among those at greatest risk of heroin initiation: a recently published report from the Centers for Disease Control and Prevention found that heroin use is most common among persons 18–25 years, and has doubled since 2002, from 3.5 per 1000 in 2002–2004 to 7.3 per 1000 in 2011–2013 (Jones, Logan, Gladden, & Bohm, 2015). In a recently published retrospective analysis of NSDUH data, the peak hazard of heroin initiation among young EMPO users was 18 years old (Cerdá, Santaella, Marshall, Kim, & Martins, 2015). Notably, those reporting EMPO use initiation at ages 10–12 had the highest risk of transitioning to heroin use in young adulthood, compared to youth who initiated EMPO use later in adolescence. A recent longitudinal study of EMPO-using youth in Ohio also found that initiating prescription opioid use before age 15 increased the risk for transition to heroin use (Carlson, Nahhas, Martins, & Daniulaityte, 2016). These studies extend former work demonstrating that early onset non-medical prescription drug use is a risk factor for the development of opioid dependence (McCabe, West, Morales, Cranford, & Boyd, 2007).
With regards to injection drug use, early studies indicated that prescription opioid injecting among young adults was rare. For example, a US study of over 4000 undergraduates found that injection drug use was reported by less than 0.5% of lifetime EMPO users (McCabe, Cranford, Boyd, & Teter, 2007). Another study of over 500 street-based EMPO users in New York City found that prescription opioid injection was reported by less than 5% (Davis & Johnson, 2008). More contemporary evidence suggests that injecting initiation is increasingly common in this population (Roy et al., 2011, Young et al., 2010). One study of rural Appalachian EMPO users found that the median time from first use of OxyContin® to injection was 3 years (Young & Havens, 2012). Although the majority of EMPO users do not transition to injection drug use, initiation rates are increasing, particularly among young people (Green et al., 2011, Green et al., 2015). Qualitative research has identified several distinct typologies of substance use transitions among young EMPO users who progress to injecting. Many begin with snorting or sniffing prescription opioids, followed by non-injection heroin use and subsequent heroin injecting (Mars, Bourgois, Karandinos, Montero, & Ciccarone, 2014), or direct progression to prescription opioid injecting (Lankenau et al., 2012a, Roy et al., 2011).
There is significant concern that increasing rates of injecting among young people may offset declines in HIV incidence attributable to injection drug use observed in the US and other Western nations over the past decade (Hadland and Wood, 2012, Surratt et al., 2011). Moreover, the incidence of hepatitis C virus (HCV) among young persons in the US has risen dramatically since 2006, with the majority (77%) of new HCV cases reporting a history injection drug use, and 82% reporting sharing of other drug preparation equipment (Suryaprasad et al., 2014). One recent study involving young persons in Kentucky, Tennessee, Virginia, and West Virginia reported that 73% of acute HCV cases cited injection drug use as the principal risk factor (Zibbell et al., 2015). The study also found a concomitant increase in the percentage of admissions to publicly-funded substance abuse treatment centres for prescription opioid injection (from 6% to over 18%), further demonstrating a link between EMPO use, drug injecting, and HCV infection among young people. In another study of people who inject drugs (PWID), younger age and prescription opioid injection (compared to the injection of other drugs) were positively associated with HCV seropositivity (Zibbell, Hart-Malloy, Barry, Fan, & Flanigan, 2014). Prescription opioid injection was also identified as an independent risk factor for HCV acquisition in a street-based sample of drug users in Montréal (Bruneau, Roy, Arruda, Zang, & Jutras-Aswad, 2012). Collectively, these findings demonstrate that youth who inject prescription opioids represent a population in need of improved access to evidence-based harm reduction and HIV/HCV prevention services.
Historically, overdose fatalities have been most common among older adults (45–54); however, recent data suggests that mortality rates have been increasing among young people, at least 10% annually over the past decade (Hedegaard, Chen, & Warner, 2015). Similar trends have been observed in the rate of hospitalizations for prescription opioid overdose among young people (White, Hingson, Pan, & Yi, 2011). A growing literature has documented the contexts, experiences, and risk factors for overdose among EMPO-using young adults. For example, recent studies have revealed pervasive personal and/or social experiences with overdose, primarily in the context of multiple pharmaceutical use – prescription opioids with benzodiazepines and other prescription medications – or combined use of opioid analgesics and heroin (Frank et al., 2015, Lankenau et al., 2012b). Polysubstance use significantly increases the risk of overdose among EMPO users, particularly when opioids are combined with other central nervous system-depressant drugs that result in respiratory depression (Webster et al., 2011). However, studies to date have shown young EMPO users have poor knowledge of opioid overdose avoidance and response strategies, and perceive prescription opioids as associated with a lower risk of overdose than illicit drugs such as crack, methamphetamine, and heroin (Daniulaityte et al., 2012, Frank et al., 2015).
In sum, the collective body of evidence demonstrates substantial vulnerability to HCV infection, overdose, and other adverse health concerns among young people who use prescription opioids extra-medically. Although harm reduction approaches have a critical role to play in the prevention of morbidity and mortality among EMPO users, the uptake and effectiveness of evidence-based interventions (e.g., needle and syringe programmes, naloxone distribution) among opioid-using young adults has been limited (Frank et al., 2015, Mateu-Gelabert et al., 2015). In this commentary, we summarize key harm reduction strategies for EMPO users, focusing on young adult populations. We discuss established and emerging interventions to reduce harms associated with EMPO use among young people, and examine structural, programmatic, and logistical barriers to their implementation. Finally, we highlight promising new avenues for research and practice to address EMPO use and mitigate related harms among youth.
Section snippets
Harm reduction for extra-medical prescription opioid users
A number of evidence-based harm reduction interventions are available for EMPO users (European Monitoring Centre for Drugs and Drug Addiction, 2015a, Wermeling, 2010). For people who inject prescription opioids, engagement in needle and syringe programmes (NSPs) reduces injection-related risk behaviour and can prevent HIV and HCV disease transmission (MacArthur et al., 2014). In addition to standalone NSPs, pharmacies are a common source of syringes for prescription opioid injectors (Zaller et
Obstacles to effective harm reduction for young adult EMPO users
Young adults who use EMPO represent a diverse and fragmented population, often disconnected from drug-using networks traditionally reached by harm reduction services (Daniulaityte, Falck, Wang, & Carlson, 2009). For example, the past-year prevalence of EMPO use among young adults in the United States is similar across levels of educational attainment (13.2% among those without a high school education, 13.1% among those who have completed high school, and 11.3% among persons attending college) (
Towards youth-centred harm reduction for prescription opioid use
Given that many EMPO-using youth do not access existing services (or experience barriers while attempting to do so), research is needed to identify innovative strategies and technologies that expand the reach of current harm reduction programmes. Since health issues vary across the EMPO-using youth population, research is also warranted to inform tailored, population-specific approaches.
To achieve these goals, community, institutional, and political support is vital. Furthermore, the meaningful
Conclusions
In sum, a growing body of evidence indicates that young people who engage in extra-medical opioid use are at high risk of transition to heroin use, injection drug use, overdose, HCV acquisition, and other harms. Medical, social, and structural interventions, grounded in a harm reduction framework, are necessary to respond effectively to this public health crisis. Community, statewide, and federal programmes that address high-risk practices (e.g., high-dose opioid prescribing, combined opioid
Acknowledgement
This work was supported by the National Institute on Drug Abuse (R03-DA037770).
Conflict of interest statement: The authors have confirmed they have no potential conflicts of interest to declare.
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